Cardiac function monitoring system and method for use in association with cardiac pacer apparatus

ABSTRACT

A diagnostic method and system for the detection and transmission of data from a remote location to a central location relative to the condition of artificial cardiac pacer apparatus. Measurements of selected characteristics of cardiac pacer pulse information including the area, height, width and frequency of the cardiac pacer pulses. Analog signals representative of various of the selected characteristics of the cardiac pacer pulses are generated with bandwidth compression means being provided for compressing the bandwidth characteristics of the analog signals as contrasted with the bandwidth of the cardiac pacer pulses. Gating apparatus serially gates the compressed bandwidth signals into a transmission means for transmission over a telephonic system to a central location. At the central location the signals are interpreted so as to predict cardiac pacer failure or other detectable malfunctions.

United States Patent Kennedy [451 May 27, 1975 1 CARDIAC FUNCTION MONITORING SYSTEM AND METHOD FOR USE IN ASSOCIATION WITH CARDIAC PACER APPARATUS [75] Inventor:

[73] Assignee: Pacemaker Diagnostic Clinic of American, Inc., Gainesville, Fla.

[22] Filed: Nov. 16, 1972 [21] Appl. No.: 307,182

James R. Kennedy, Gainesville. Fla.

[52] US. Cl..... 128/2.05 R; 128/2.06 R; 128/21 A; 128/419 PT [51] Int. Cl A6lb 5/04 [58] Field of Search 128/205 R, 2.05 T, 2.06 A, 128/206 B, 2.06 F, 2.06 R, 2.1 A, 419 P OTHER PUBLICATlONS Gregn et al., Medical and Biological Engineering,

Vol. 9, pp. 503-508, 1971.

Primary Examiner-William E. Kamm Attorney, Agenl, 0r Firm-Cushman, Darby & Cushman [57] ABSTRACT A diagnostic method and system for the detection and transmission of data from a remote location to a central location relative to the condition of artificial cardiac pacer apparatus. Measurements of selected characteristics of cardiac pacer pulse information including the area, height, width and frequency of the cardiac pacer pulses. Analog signals representative of various of the selected characteristics of the cardiac pacer pulses are generated with bandwidth compression means being provided for compressing the bandwidth characteristics of the analog signals as contrasted with the bandwidth of the cardiac pacer pulses. Gating apparatus serially gates the compressed bandwidth signals into a transmission means for transmission over a telephonic system to a central location. At the central location the signals are interpreted so as to predict cardiac pacer failure or other detectable malfunctions.

28 Claims, 23 Drawing Figures ARE/9 HEIGHT DMMIHATD cLccK 7 Man/a 555mm MAY 2 71975 SHEET PATENTEB MAY 2 7 I975 SHEET xv .mw Nam PATENTED [#3271975 3.885.552

' SHEET 1o FILTER {225 VOL H65 can/M014 0 MUL 7/.

PATENTED MAY 2 7 I975 SHEET CARDIAC FUNCTION MONITORING SYSTEM AND METHOD FOR USE IN ASSOCIATION WITH CARDIAC PACER APPARATUS BACKGROUND OF THE INVENTION The fundamental idea of monitoring cardiac pacer systems stems from the fact that people who have implanted heart cardiac pacers live in jeopardy because batteries in these implanted heart cardiac pacers fail in a random way. People who have cardiac pacers are those, who for one reason or another, have a physical defect wherein the electrical conduction system of their own heart has broken down. This is usually associated with the process of aging, a great percentage of the people being over the age of 65. Occasionally, a coronary or some sort of dramatic event can also lead to the failure of the conduction system of the heart but usually it is aging which precipitates the ailment.

The problem is, then, that the normal impulses that stimulate the heart, and cause it to beat at a normal rate, slow down during rest period and speed up under exertion, do not arrive at the correct points in the heart muscle for causing the ventricles (the lower portion of the heart or the main pump of the heart) to contract. As a result, instead of beating at a normal rate, the heart may beat at a very slow rate, anywhere from about l to perhaps 40 beats per minute (bpm), wheras 70 bpm would be normal for a resting, nonexerting adult.

In many patients the disease affects normal cardiac pacing function such that it becomes intermittent. During that period of time that the heart is beating at the slow rate it is very likely that such a patient will faint, fall down and injure himself. Since, as previously mentioned, the patients are old, sucha condition could lead to further medical problems. Other obvious problems arise. For example, a failure may occur when a person is driving, or operating other types of equipment.

People who suffer from a failure of their own electrical conduction system of the heart (i.e., cardiac pacer) can be implanted with a battery powered electronic device which provides a stimulus to the heart through a connection with an electrical wire, to the heart muscle. This stimulus keeps the heart pumping at a normal rate. While such devices do not vary the rate of pulses with exertion and rest, it does keep the heart going at about 70 beats per minute. ln the case of a patient with an intermittent cardiac pacer the physician will elect to implant what is called a Demand cardiac pacer which actually listens to the heart on the same wires that is sends pulses on. If the heart beats faster than a certain rate the artificial cardiac pacer does not fire. In other words, the artificial cardiac pacer allows the hearts own pacemaker to control, but as soon as the hearts cardiac pacer fails to put out a beat within a certain length of time (i.e. when a rate lower than perhaps 70 beats per minute is detected), then the artificial cardiac pacer immediately starts sending impulses and assumes control of the cardiac pacing function.

After initial installation of an artificial cardiac pacer by known surgical techniques the patient is required to have periodic checkups so that the cardiac pacer function may be monitored for possible battery or other failure.

A major problem with these devices is that battery failure is not precisely predictable statistically and while statistics do exist they are unfortunately gathered after pacer failure has occurred. Further, present cardiac pacers available have a functional life expectancy of about two years, but individual ones may not exceed this, and in fact may rather unpredictably fail before this statistical determined period. Usually approximately percent of cardiac pacer failures are battery failures, and the remaining 10 percent are a result of other types of failures, the next most common failure being in the leads themselves. Electronic component failure in artificial cardiac pacers is generally a very small factor. However, all of these factors must be considered when diagnosing a possible malfunction.

Many cardiac pacers are the demand type, mentioned previously, when listen to the heart, which means that the number of times the cardiac pacer fires in a given length of time, depends entirely on the patient. If the patient has an intermittent block, for example once every 6 months, for 5 minutes, the cardiac pacer in question will in all probability last longer than one pulsing constantly.

The number and kinds of variables that exist make an accurate a priori prediction of the lifetime of a given cardiac pacer simply out of the question. The problem therefore is that of measuring the cardiac pacer impulse, the interval between impulses and some charactertisics or set of characteristics which will allow determination in advance of a critical situation, i.e. when cardiac pacer is about to fail,

One such characteristic is that as the battery starts to fail, the voltage output of the pulses starts to drop and generally as the voltage drops the width of the pulse changes. Further, in most cardiac pacers the rate of firing changes.

Ordinarily, the artificial cardiac pacer impulse varies from about 5 to 10 times the: threshold of the normal cardiac pacer pulse, the minimum required current. For example, usually the heart requires about 1 ma. current between the electrodes once they are planted to stimulate the heart, whereas standard artificial cardiac pacers generally deliver 10 to ll ma. There is therefore ordinarily a wide zone between what is actually necessary to maintain the heart function and the actual output of the device. This provides a stabilizing factor so that predictions may be more accurate. In addition, once the pacer is implanted, the heart develops resistance pacing pulses and that normal threshold may well increase. However, such increase is usually not more than a factor of 2. In addition, since most pacers generally are powered by 4 or 5 miniature batteries, present monitoring techniques are geared to detect when the first of those 5 batteries has failed, which means that the safety factor is decreased by about 10 to 20 percent. In any event, a failure of not only one cell but generally two can be tolerated before the patient is in any danger. It should be cautioned however that when a cell does fail, it fails very rapidly. The battery voltage remains almost constant throughout the lifetime of the battery. Therefore, changes may be detected in the pacer output pulses by comparing measurements from one checkup to another.

Now that the basic problem has been examined, there remains now to point out the basic parameters of artificial pacers and the approach to monitoring same from a remote location at relatively frequent intervals. Research has been conducted into what should be detected in order to predict power failure. It has been discovered that the pulse height which may be detected with a highspeed electro-cardiograph is an important parameter. The rate of the pacer is also generally dependent upon battery voltage, and in some cardiac pacers the width of the impulse is dependent upon battery production. By making measurements of these various parameters notice should be taken, depending on the type of cardiac pace, of a sudden change in the value of that critical parameter. For instance, a pacer that beats at 70 bpm for 24 months and suddenly over a period of a few weeks changes to perhaps 65 bpm would be a critical sign of imminent failure. This sudden change in rate in most cardiac pacers is one of the prime indicators of the fact that the battery voltage, in the total stack, has changed by the amount of one cell.

Therefore, according to previous discussion, making measurements of certain characteristics of the pacer impulse, specifically impulse amplitude, width, shape and interval, as detected by a special high-speed electrocardiograph, a satisfactory analysis may be made of the cardiac pacers functional condition. This analysis even includes establishing the status of the Wire lead connecting the pacer with the heart muscle. If such measurements are repeated at regular intervals, it is possible to detect subtle changes in the impulse as the batteries begin to run down. When these signs occur, the pacer may be replaced with the assurance that the patient has had the maximum use of his old pacer, and more important, the minimum amount of pain and discomfort.

In research clinics, where these techniques have already been applied with great success, it has been found that a large volume of background information on the various pacer types is vital. Furthermore, the introduction of computerized analysis and record storage is essential. The final result is that proper cardiac pacer follow up analysis is a very specialized science which requires a multi-disciplinary centralized operation, and if it is going to render effective service to the patient.

Unfortunately, it has been shown that, in order to be certain of reliable determination of the onset of battery failure, it is necessary to make pacer tests as frequently as once a week during the last few months of battery life. This is a result of the fact that the battery cell voltage decays very quickly once exhaustion begins to occur. This works a hardship on the patient since it is often difficult and inconvenient for older people to travel so frequently to a clinic or hospital for analysis. Thus the requirement of centralization of expertise has made it difficult for such services to reach the very people who need them so desperately. It was felt therefore that by connecting the patient with a central clinic by telephone it could in effect bring the clinic to the patient instead of vice versa.

The fundamental stumbling block is the fact that it is theoretically impossible to send the pacer impulse per se over a telephone line without distorting its shape severely, since the frequency bandwidth of the impulse exceeds that of the telephone system by a factor of about 100 times. Such distortion would render the analysis meaningless.

Earlier attempts at phone analysis by others encountered this problem. while some equipment was developed to do pacer followups over the telephone, the only measurement possible was the pacer rate and, in one case, the patient pulse rate. However, the measurement of essential impulse wave-form parameters was impossible without actually bringing the patient into the clinic. In fact, authorities believe that the measurement of changes in two or more of these parameters is necessary for a conclusive diagnosis of impending failure.

The solution, in this disclosure, is a unit which will actually make the waveform measurements in the patients home. Then, the device sends the result of the measurement over the phone, rather than sending the impulse itself. In another embodiment, the pulse itself is transmitted via a novel electrical system. This-is accomplished by processing the signal in such a way as to compress the bandwidth of the parameter measurement, or, in the latter embodiment, the pacer impulse itself.

The device makes possible the establishment of the needed central data bank for providing essential pacer followup services on a nationwide basis over conventional telephone lines. Information may be transmitted to a clinic by the patient, no matter where he may be. This data is received at the clinic and analyzed by a digital computer, which maintains a constantly updated file on the patients cardiac pacer status. In this way, the medical doctor responsible for the patients care can be advised of the cardiac pacers condition by the clinics reports. This permits the physician to provide truly adequate patient care since he can coordinate the cardiac pacer evaluations with his own program of patient examinations.

One helpful part of cardiac pacer evaluation is to obtain an ordinary electro-cardiogram. Along with the other necessary measurements, the waveform analyzer automatically transmits such a record. This permits the clinic to make several important pacer determinations, such as competition, l:l response, polarity and sensing.

While diagnosis of the heart via this ECG is not the clinics ordinary function, all cardigrams may be reviewed by a specially trained coronary care nurse and forwarded to the physician as a part of his report. In this way, serious heart malfunctions may also be detected by the clinic or the patients doctor as an additional benefit of the program.

It is therefore an object of the present invention to provide a system and method which obviates one or more of the disadvantages and limitations of the described prior arrangements.

It is another object of the present invention to provide a system and method wherein a patient can communicate with a diagnostic center at a remote location, at intervals frequent enough so as to provide adequate warning of an impending pacer failure.

It is another object of the present invention to provide a system and method for cardiac pacer or other detectable patient functional failures without the necessity of direct physical contact with the diagnostic location.

SUMMARY OF THE INVENTION A diagnostic system for the detection and transmission of data relative to the condition of artificial cardiac pacer apparatus has been provided wherein measurements of selected characteristics of patient functions are taken and transmitted to a central data clinic for interpretation so as to predict cardiac pacer failure or after detectable malfunctions.

For a better understanding of the present invention, together with other and further objects thereof, reference is directed to the following description, taken in connection with the accompanying drawings, while its scope will be pointed out in the appended claims.

DESCRIPTION OF THE DRAWINGS FIG. 1 is a functional block diagram of the system of the present invention;

FIG. 1A illustrates a plan view of the apparatus of the present invention with the patient, in Lead I configuration:

FIG. lB shows an embodiment of FIG. 1 utilizing time expansion for signal transmission purposes; I

FIG. 2 is a detail of the high speed electrocardiograph (ECG) shown in FIG. 1;

FIG. 3 is a detail of a conventional ECG used in the embodiment of FIG. 1.

FIG. 4 is a schematic of the pacer pulse amplifier shown in block form of FIG. 1;

FIG. 5 illustrates in schematic form the pacer pulse selector of FIG. 1;

FIGS. 6A-B-C are various forms of the pulse width hold control circuit;

FIGS. 7A-B-C are variations of the peak amplitude amplifier of the present invention;

1 FIGS. 8A-B are circuits showing different embodiments of the area amplifier of the present invention;

FIG. 9 is an illustration of the analog commutator 4 of FIG. 1;

FIG. 10 is a functional block design of the central monitoring console of the present system;

FIGS. 11-A B-C are various embodiments of the demodulator 217 of FIG. 10;

FIG. 12 is a circuit diagram of the first form of the demodulator 217 shown in FIG. 11A:

FIG. 13 is a circuit diagram of the second form of the demodulator 217 shown in FIG. 11B; and

FIG. 14 illustrates the output circuit 218 of FIG. 10.

DESCRIPTION OF THE PREFERRED EMBODIMENT SystemsDescription The transtelephonic cardiac pacer waveform analyzer consists of four basic subsystems: (1) an analog pacer analysis system; (2) an identification code system; (3) a voltage controlled oscillator audio system and (4) a control logic system. These are presented schematically in FIG. 1.

Pacer Analysis System This system comprises three branches each of which provides its own output. All branches share a common preamplifier 1 and hum notching filter 2. This preamplifier l is usually connected to the patient in a lead I configuration, i.e. one pickup for each wrist (signals L and R) and a ground (signal GR) to the other side of one. Other configurations known as lead II and III are also possible but not usually used. A differential voltage is provided with a gain of about 5 with high common mode rejection and a bandwidth well in excess of 100 KHz.

60 Hz hum notch filter 2, of an active type, is an integral component of the pre-amplifier 1. The filter function may be bypassed for pacer output in excess of 45 mv, to avoid excessive ringing.

Following the filter 2, the signal path encounters a two-way branch A-B. The path through amplifier 3 provides a conventional ECG. This amplifier 3 has a gain of about and a bandwidth of I00 Hz. Consequently the ECG channel has an overall gain of and a bandwidth of 100 Hz.

The output of amplifier 3 is delivered to an analog input on a commutator apparatus 4 the function and operation of which will be explained further in the discussion.

Another signal path A through variable gain amplifier 5 constitutes the beginning of two pacer analysis channels. Amplifier 5 constitutes a variable gain amplifier with 4 discrete selectable gain steps and a short risetime on the order of 20 us. Amplifier 5, in combination with a two-step input voltage divider 6, provides sufficient gain for the analysis of pacer impulses from as low as 300 uv to about 1.5V. In order to establish a convention for measurement, it is necessary that the pacer pulse at the output of amplifier 5 be positive going for subsequent analysis. However, there is no guarantee of the input polarity, since pacer impulses may be either positive or negative going. Furthermore, patient error in attaching the electrodes can produce an unwanted inversion. Consequently, amplifier 5 provides both non-inverted and inverted outputs. This guarantees that at least one of the outputs of amplifier 5 will be positive going.

The two outputs are delivered to the positive pulse selector 7 which detects the positive going output and switches it through to the subsequent circuitry.

At this point the signal path encounters another twoway branch C-D. One branch D goes to a keying system including logic circuit 10 and 11 and associated switches 12 and 13, while the other branch C is conducted to area and height analyzers 14 and 15 respsectively through switches 12 and 13. Area and height analyses are accomplished by sample and hold techniques, while the keying system generates the appropriate control signals for the sampling and holding gates.

A primary requisite of these analyses is that they be performed on the pacer impulse and not on some other signal such as the heart response or R wave, as it is known, or noise. Consequently, the keying and analysis circuitry must provide a means of recognizing the pacer impulse and discriminating against other signals, even though in some cases the unwanted signals may be of much higher amplitude.

One of the distinguishing characteristics of the pacer impulse is that it has a very fast risetime. This risetime is typically in the microsecond range at the monitor input and about 20 us at the output of positive pulse selector 7. By contrast, the electrical impulses normally originating in the heart and common noise sources such as 60Hz line noise have rise times on the order of 10 to 20 ms.

Another common source. of noise is that generally originating from certain types of electrical appliances being operated from the same power line. These generally have fast rise times but very short duration. Since these individual pulses generally are only fractions of microseconds long, they are distinguished from cardiac pacer impulses principally by the pulse widths since cardiac pacer impulses are commonly in the 1 ms range.

The cardiac pacer impulse, therefore, has two sets of distinguishing characteristics which separate it from the other types of electrical signals that are likely to be picked up from the patient, namely, a very fast rise time, and long pulse width or nominally l to 2 ms. Consequently, the output from positive pulse selector 7 is sampled for these two characteristics.

In the first instance, a differentiator 8, including a capacitor Ca and resistor Rd, passes only signals with rise times faster than 100 us, while in the second case, an integrator 9, including capacitor C, and resistor R,, passes only signals with time widths in excess of 250 us. These two sets of signals pass to a pacer pulse selector logic unit 10 which compares these two characteristics in order to distinguish between the pacer impulse itself and whatever other electrical signals may be present. This logic system functions in such a way that any impulse which meets the fast rise time criteria will cause a switch driver 11 to force the switch or selector gates 12 and 13 into a SAMPLE mode for a period in order of 2.5 ms. This permits the electrical impulse to pass into both area integration amplifier l4 and height amplifier during that period. Having thus sampled every fast rise time pulse, the pacer pulse selector logic 10 will, at the end of 2.5 ms sampling period, either switch to a HOLD condition, if in fact a pacer pulse has been observed, or immediately switched ZERO a Zero or cancel condition if the pacer pulse has not been sent. In the HOLD condition, integration amplifier 14 presents an output to the commutator 4 which is proportional to the area underneath the impulse curve which occurred during the 2.5 ms sampling period. Likewise, in the HOLD condition, the height amplifier 15 presents an output to the commutator 4 proportional to the peak impulse amplitude during the 2.5 ms sampling period. If a pacer pulse has not been observed, the switches 12 and 13 are set to ZERO, which cancels the output of both amplifiers 14 and 15.

In the case of the cardiac pacer impulse, the length of time that the area and height output are displayed, that is to say, the length of the HOLD period, depends on the actual width of the cardiac pacer impulse, as measured at some fixed percentage of the maximum impulse amplitude. This is accomplished by way of a pulse width multiplier 16 which engages each time a pulse is sampled. The width multiplier 16 observes the pulse output of the pulse selector 7 and generates, in conjunction with the pacer pulse selector logic 10, an impulse which causes the HOLD period to be 100 times that of the actual cardiac pacer impulse width. Since the actual width is too narrow for telephone transmission, the multiplication by 100 compresses the frequency bandwidth by 100 provides for easier measurement and encoding, as will be described later in the specification.

The net effect of the pacer analysis system is such that only cardiac pacer impulses are measured and pulses are delivered to the commutation 4 having a width 100 times that of the cardiac pacer pulse width. Further, the latter impulse amplitudes are proportional to the integrated pacer impulse area and the peak pacer impulse amplitude respectively and the interval of time between each of the pulses is precisely the same as that interval of time between each successive cardiac pacer impulse.

By this method, the critical impulse parameters of interval, height, area and width are transformed into a series of electrical impulses with compressed bandwidth characteristics that are compatible with transtelephonic transmission.

IDENTIFICATION CODE SYSTEM The purpose of the Identification Code System is two-fold: Firstly, it transmits a unique binary number which identifies which individual waveform analyzer is sending the data. Thus, it identifies the patient automatically. Secondly, it automatically transmits the scale settings selected for variable gain amplifier 5 and divider 6.

The above is accomplished by transmitting a 12-bit binary word, the first 9 bits of which identify the particular transmitting unit and the last 3 bits of which identify the scale settings.

The ID code system contains a clock 17, which is coupled through a gate 31.3 to a 12-bit programmable shift register memory 18 and a word generator 19. Appropriate pulses from a control logic system reset the system memory before each use by clearing and resetting the predetermined ID number.

When the commutator 4 is switched to be responsive to the ID, a selector pulse from a 4-bit counter and decoder 26 sends a pulse to open the ID clock gate 313 and allows clock pulses to step a shift register memory 18. The ID number stored in the memory is read into a word generator 19 serially.

The word generator 19 combines the ID number with a beginning of word pulse, bit sync pulses and an end of word pulse to form the ID code word. This word is then delivered to the appropriate ID analog input on the commutator 4.

The output amplitude level of the ID pulse is standardized and serves as a reference level for a voltage controlled oscillator (VCO) system 20, to be described further in the specification. The generator 19 also signals a control logic gate 29 at the conclusion of the end of word pulse which is appropriately labelled in FIG. 1.

THE CONTROL LOGIC SYSTEM The sequence in which the data is transmitted is established by the control logic. It is desired to transmit in the following sequence: ID; ECG; ID; Area/Width; ID Height/Width; ID Such a sequence therefore transmits the information with individual check on proper coding. In order to do this, control is affected in a way to be described below.

When power is applied to the instrument, initializer 21 transmits a reset pulse through an OR gate 22 to the ID memory 18 and 4-bit commutator Counter-Decoder 26. The same pulse also is sent through an inverter 36 to reset a flip flop 23. This readies the logic for operation. Depressing Start button 24 sets the flip flop 23 enabling output O. The Q output then opens NAND gate 25 which allows the various stepping pulses, to be described to reach the commutator Counter-Decoder 26. The other 6 output of flip flop 23 momentarily resets the commutator clock 27 to the beginning of its cycle, and also causes monostable multivibrator 28 to fire once. This impulse from monostable 28 is ORed at 29 into the Counter/Decoder 26 input and sets the counter 26 to the first ID position. Finally, the 6 output of flip flop 23 opens a gate 30 to enable an audio output amplifier 31 which drives speaker 32. The output of the Counter/Decoder 26 selects or shifts the analog commutator 4 into a selected position in sequence each time it switches its outputs, and causes the ID input to the commutator 4 to be sequentially switched through to the VCO 20. As previously mentioned, it simultaneously gates on the ID clock 17 and causes the ID word to be sent. The VCO transforms the varying analog voltage output of the commutator (in the present case, the ID) into a varying audio frequency tone with a nominal frequency of 1400 Hz. When the ID word is complete or shifted through the generator 19 by clock pulses 17, the word generator signals completion by sending an End of Word" pulse which is ORed at 29 into the Counter/Decoder 26 clock input, which steps the Counter 26 to the ECG 3 function and switches the commutator 4 accordingly.

After a selected period of perhaps ten seconds determined by a time setting of the commutator clock 27 its first pulse is emitted, which is ORed at 29 into the Counter/Decoder 26 clock'input. This pulse terminates the ECG phase and switches the counter to the next ID sequence. The cycle repeats itself as the next ID is transmitted and subsequently ends, causing the Area 14 output to be transmitted, to another ID, the Height 15 output and still another ID to be sent. At the conclusion of the last ID, the Counter/Decoder 26 sends an end of message signal pulse which is ORed at 22 which simultaneously resets the ID memory 18, the Counter/Decoder 26 and the flip flop 23. This in turn actives G which silences the audio tone through gate 30 and resets the instrument to await the beginning of another data sequence.

THE VCO AUDIO SYSTEM The voltage controlled oscillator VCO transforms into audio tones, the outputs of the various channels of the commutator 4. The frequency of the tone is proportional to the amplitude of applied analog voltage. The audio tones pass through gate 30 to amplifier 31 which delivers the tone to speaker 32. The speaker in turn couples the tone accoustically to the telephone 33 microphone 33, hence sending the data to the remote clinic where it is demodulated, recorded and analyzed.

The following is a description of the circuits used in the apparatus of FIG. 1.

HIGH SPEED ELECTRO-CARDIOGRAM ECG PREAMPLIFIER The schematic wiring diagram of the high speed ECG preamplifier is found in FIG. 2. It is through this circuit that the actual electrical connection to the patient is made. This connection is made by way of the three pa tient electrodes L, G and R. Attachment to the patient may be made in any of a variety of ways, as previously mentioned, but typically it is made in the conventional lead I mode. That is, the active electrodes L and R are connected to the patients left and right arms respectively, usually at the wrists, according to standard medical convention. The patient ground electrode G is generally attached to one of the same limbs as one of the active electrodes except the connection is on the opposite side thereof. For example, in FIG. 1A the usual connection scheme is illustrated, one active electrode is attached to each wrist by means of a wrist clamp type electrode 37R and 37 (L-G) respectively. The ground electrode G is then attached to the opposite side of one of the wrists being held in place by the same wrist clamp 37 (L-G) assembly. Research has shown that this close proximity of the ground electrode to an active electrode will not change the pacer impulse parameters measured by more than I or 2 percent with respect to a system where the patient ground lead G might be connected to some more remote portion of the body.

It has been found, in situations where the electrical noise ambient is high, that the connection of a second patient ground, not shown in FIGS. 2 or 3, but essentially parallel with the patient ground G, can in extreme cases reduce the effect of this interference on the cardiac pacer measurements. However, if this second ground electrode is attached to the opposite side of the other wrist in the same manner as the first patient ground, that is to say there is a ground electrode on each wrist and an active electrode on each wrist, a noticeable modification of the impulse waveform parameters will occur. Specifically the impulse amplitude will be reduced approximately 16 percent from the single ground configuration and a decided slowing of the rise time of the leading edge of the cardiac pacer impulse is seen. The latter effect is reflected principally in a reduction of the area under the cardiac pacer curve. Consequently, when double grounding is required, appropriate compensations must be made in whatever computer analysis is conducted on the measured parameters.

In any case, the active electrodes L and R pick up the electrical impulses of both cardiac pacer and heart from the skin of the patient and route these signals to two unity gain amplifiers 40 and 41 which function primarily as impedance transformers providing the overall preamplifier 1 with an input impedance in the order of 44 M ohms.

The signals from amplifiers 40 and 41 are delivered to amplifier 42 which is a conventional unity gain differential amplifier with a balanced input. A potentiometer 43 allows the balancing of the input for maximum rejection of common mode noise. The output of amplifier 42 is delivered to amplifier 43 which has a gain in the order of 5 plus.

If excessive 60 Hz noise is present in the input to amplifier 43 then amplifier 44 may be enabled by moving switch 45 to the G position, thereby coupling amplifier 44 to amplifier 43. This amplifier employs a 60 Hz notch filter feed-back network shown generally at 48. When enabled, amplifier 44 delivers a signal, proportional to the 60 Hz component present at the noninverting input of amplifier 43,, to the inverting input of amplifier 43 by way of the resistor 46 and potentiometer 47. i

By adjustment of a potentiometer 49 in filter 48, amplifier 44 can be tuned to precisely 60 Hz. By adjustment of potentiometer 47, the amount of adjusted 60 Hz component can be adjused to exactly cancel any 60 Hz component available attempting to find its way through amplifier 43. Hence, when the amplifier 44 is engaged, it and amplifier 43 function as a 60 Hz notching filter with a Q of approximately 10 and a gain of 5. Otherwise when switch 45 is at the N position 43 acts as a conventional amplifier with a gain of 5.

The output from amplifier 43 is split and is conducted to point A (see FIG. 1) where it provides the input to the pacer pulse amplifier 5 and to point B where it provides the input to the conventional ECG amplifier 3.

THE ECG AMPLIFIER The illustrative diagram of the ECG amplifier 51 is found in FIG. 3. The ouput from the preamplifier of FIG. 2 enters the circuit at point B and is AC coupled thereto by means of the RC network 50. A potentiometer 52 allows for the cancellation of internal offset of bias in the amplifier, while the addition of negative voltage through a resistor 53 to the inverting input deliverately produces a positive offset of approximately 2.5V at the output of amplifier 51.

The purpose of this offset is so that the baseline of the electrocardiagram will be at center scale when read out at the decoding device at the clinic. This is necessary because the electrical impulses produced both by the heart and by the cardio pacer may be either positive or negative going.

The gain at the output of amplifier 51 at low frequencies is in the order of 200, while the presence of capacitor 54 in a feed-back network causes the amplifier 51 to have a high frequency roll off of approximately 3dB at 100 Hz.

Even though the output voltage at the output of amplifier 51 is nominally plus 2.5 volts, it is possible for transient excusions induced by motion in the patient or a physical disturbance of the patient electrode wires, to exceed i 10 volts.

Such extraordinary excursions would cause a disruption of the analog commutator 4 which follows the circuit. Accordingly, this problem is overcome by the insertion of a 10 to l divider 55 which reduces the entire voltage output of the amplifier by a factor of 10 at its final output point C. Hence, the net gain of the amplifier is only 20; however, transient voltage variations are limited to about i 1 volt.

The output branch A of FIG. 1 is fed to pacer pulse amplifier of FIG. 4, described below.

PACER PULSE AMPLIFIER The illustrative diagram of the pacer impulse amplifier is shown in FIG. 4. The signal enters from the preamplifier of FIG. 2 at A and encounters a selectabble divider 60 controlled by a switch 61. This allows the amplifier to be operated at normal gain, or at a gain reduced by a factor of approximately 100, depending on the setting of the switch i.e. either directly to A or through the circuitry 60 respectively. The other gang on this switch, 61, is found in FIG. 2. When switch 61 is set to reduce the gain of the pacer amplifier, by the nominal factor of 100, the other gang 45 in FIG. 2 disables the 60 Hz notch filter (amplifier 44) in the preamplifier to avoid excessive ringing. Simultaneously, the identification code system 18 is apprised of the actual position of the switches 45-61 and 6, as shown by the chain line of FIG. 1. From switch 61 the signal passes to amplifier 62 the gain of which in this embodiment is selectable in four steps by means of switch 63. These gain steps are selected nominal valves of l, 3, and 30. Switch 63' ganged to switch 63 signals the identification memory 18 shown in FIG. 1 as to the position of the gain setting.

The pacer signal passes from amplifier 62 to amplifier 64, which has a nominal gain of about 22. The precise gain setting is controlled by potentiometer 65 which acts as the overall system calibration adjustment.

Amplifier 302 is a non-inverting unity gain amplifier which has a pair of diodes 66-66 inserted in the output. Consequently, only positive going signals will occur at 66 from the amplifier 302. However, since feedback for this amplifier is obtained from point 66, the feedback path includes the effect of the forward resistance of the diode 66 and insures that the voltage level at 66 is always the same as any positive voltage at the positive input of amplifier 302. This branch of the circuit then takes all positive going signals and delivers them undistorted to output 67. Negative going signals cause the amplifier 302 to try to go into negative saturation. The series diode at 66 prevents any negative current from following back from 67, while the shunt diode 66' holds the amplifier output at about O.7 volts.

On the other hand, an amplifier 303 represents the inverter version of the same ideal diode circuit above. Here, the operational amplifier 303 is connected similarly as a unity gain invertor with the pair of diodes 68-68 again appearing in the output and feedback cir cuits. As a result, any negative signal which is applied to the input of 303 is inverted and delivered undistorted to lead 67. However, positive going input signals cause the amplifier to try to go into negative saturation which is again inhibited from reaching output lead 67 by the diode array 68-68.

In effect then, amplifier 302 delivers positive going signals to lead 67 and is inoperative or negative going signals, while amplifier 303 inverts and delivers, aspositive signals to lead 67, all negative going signals applied to its input and is inoperative on positive going signals.

' The net result is that the system comprises of amplifiers 302 and 303 represents an ideal absolute value circuit whish is substantially free from all signal distortion.

The output lead 67 is delivered to point F and from there to subsequent pacer keying circuitry described further, and is also delivered to a sampling gate 69 which is keyed from point K, through resistor 70, and delivers the sampled signals to points D, E.

PACER PULSE SELECTOR The schematic wiring diagram illustrative of the pacer pulse selector 10 of FIG. 1 is found in FIG. 5. The pacer pulse from point F of FIG. 4 is branched to two amplifiers 81 and 93. The input of amplifier 93 is derived from differentiator 82, which has a time constant of approximately 100 us. A gate combination 83-83' represents a one shot multivibrator having 2.5 ms pulse output. This multivibrator 83-83 is triggered by the negative going impulse corresponding to the leading edge of the cardiac pacer spike at 82, if the impulse at F has a risetime shorter than approximately 100 us. If, on the other hand, the impulse appearing at point F has a rise time which is longer than 100 us, the impulse at 82 will be of insufficient amplitude to activate amplifier 93 and trigger the multivibrator 83-83.

When triggered, 83-83 produces an output pulse at its output 84 which is negative going and with a width of nominally 2.5 ms. The levels of this impulse are those of standard TTL logic blocks. This signal is then delivered to Zener diode 85 and transistor amplifier 86 which produces a 2.5 ms wide impulse, with a high value of nominally 12 volts and a low value of 5 volts, which is used to drive subsequent analog sampling circuits. That is, multivibrator 83-83 generates the basic interval during which subsequent analysis circuitry is activated.

It should be pointed out, however, that the sampling one shot 83-83' will be inhibited from firing, if the logic level at input point 87 is low. This can only occur if the logic levels at the output of one shot 83-83' and point M (width display circuit to be described later) are 

1. A system for providing transtelephonic information for a plurality of patients remotely located from a central data processing clinic, the information to be transmitted being related to coronary functions and including artificial cardiac pacer pulse information, comprising: means responsive to cardiac pacer pulses including bandwidth compression means for producing outputs representative of selected characteristics of said cardiac pacer pulses, said outputs having a bandwidth substantially less than the cardiac pacer pulses; a transmission means; control means for sequentially producing gating signals for sequentially gating each of said respective outputs to said transmission means, said transmission means responsive to said outputs for producing output audio signals indicative respectively of each of said outputs.
 2. The apparatus as described in claim 1 wherein said means responsive to cardiac pacer pulses includes means adapted to be coupled to the patient for detecting cardiac pacer pulses and further comprises means for discriminating between cardiac pacer pulses and noise including: a circuit means for detecting input signal rise time less than a selected maximum and; a circuit means for detecting pulse duration greater than a selected minimum; sample and hold means responsive to said circuit means for storing said signals over their respective intervals, if said respective maximum and minimums occur and reset means for cancelling storage if either of said maximum and minimums are absent.
 3. The apparatus as described in claim 2 wherein said sample and hold means include peak amplitude storage means responsive to the amplitude of the sampled signal, said storage means charged to a maximum in accordance with the maximum amplitude of said input, and area storage means responsive to the total response of said input for developing an area signal indicative of the area excursion of said input pulse, and means for developing from said area signal a signal indicative of the width of said input pulse.
 4. The apparatus of claim 3 further including clock means providing a particular frequency clock signal as a timing basis, width detector means responsive to the duration of said input as determined through use of said timing basis for producing an output indicative thereof and means for expanding said width indicator by a selected factor for increasing the time scale thereof.
 5. The apparatus of claim 4 wherein the means for expanding the signal width is a frequency divider circuit for generating a different frequency clock signal as a timing basis.
 6. The apparatus of claim 2 wherein said discriminating means comprises a differentiator and integrator for respectively detecting the maximum rise time and the minimum duration.
 7. The apparatus of claim 1 further including identification memory means for generating an identification output uniquely indicative of one of said plurality of patients and including means coupling said identification output to said transmission means.
 8. The apparatus as described in claim 7 wherein said identification memory means includes a storage register which stores sequential bits indicative of the identification of said one patient.
 9. The apparatus as described in claim 8 wherein said storage register is a shift register having selected stages set for uniquely identifying the patient.
 10. The apparatus of claim 7 wherein said control means includes logic means for producing gating signals for sequential delivery of the respective outputs and identification data.
 11. The apparatus as described in claim 7 further including an electrocardiograph for delivering another related coronary function namely electrocardiographic (ECG) responses.
 12. The apparatus of claim 11 wherein the system includes a clock for sequentiAlly driving said identification means, and sequencer means responsive to said clock for sequentially gating the respective outputs, the identification data and the ECG responses.
 13. The apparatus of claim 12 wherein said sequencer means includes commutator means for providing a path each for the outputs, identification data and ECG responses and a gate for sequencing said commutator according to a selected cycle for opening one commutator output at a time for the transmission means.
 14. The apparatus according to claim 1 wherein said means responsive to cardiac pacer pulses include: means responsive to each of the plurality of cardiac pacer parameters for storing same at a selected rate commensurable with real time and read out means for each stored parameter for producing the output at a second rate substantially slower than the input rate such that the output signals produced represent the actual cardiac pacer parameters but on a longer time scale thereby permitting telephonic transmission thereof.
 15. The apparatus of claim 14 wherein said storage means includes: a shift register responsive to said parameters; a clock, said clock driving the register at the selected rate for storing each of the parameters in real time and means for dividing the clock output, for clocking out the information at the second rate substantially slower than the first rate such that the output wave forms are compatible with band pass characteristics of the transmission system, thereby permitting transmission of the actual wave form substantially undistorted to the central location.
 16. The apparatus as described in claim 1 wherein said means responsive to cardiac pacer pulses comprises: analysis means for converting said pulses into analog parameters of said cardiac pacer pulse characteristics for transmission to said central location.
 17. The apparatus of claim 1 wherein said means responsive to cardiac pulses comprises a storage means for expanding the cardiac pacer pulses into signals proportional in wave form characteristics to the cardiac pacer pulses, but with a frequency spectrum compressed so as to be compatible with transmission means.
 18. The apparatus according to claim 1 further including: means at the central location responsive to said transmitted signals from the remote location, for processing same in accordance with stored criteria to generate cardiac pacer performance information unique to the patient and means for displaying said cardiac pacer performance information.
 19. The apparatus of claim 18 wherein said means at the central location includes demodulator means responsive to the incoming signals from the remote location for producing output signals indicative of the information transmitted from the remote location.
 20. The apparatus of claim 19 wherein said demodulator comprises: a phase-locked loop detector for producing a variable output in response to the input signals and a voltage controlled multivibrator for producing a reference output for controlling phase continuity of the detector thereby providing an output indicative of the remotely transmitted information.
 21. The apparatus of claim 19 wherein said means for displaying said cardiac pacer performance information includes an output circuit means and a plurality of record keeping devices including a pen, tape and computer memory recorders, said output circuit means generating a plurality of outputs for said plurality of record keeping devices.
 22. A method of diagnosing the condition of relevant coronary parameters of a patient remotely located from a central diagnostic clinic, including: coupling a detector means to a patient for detecting waveforms of said parameters; analyzing said waveforms for preserving certain selected characteristics of said waveforms indicative of the coronary condition of the patient including the step of compressing the bandwidth of the selected characteristics of said waveforms; transmiTting said bandwidth compressed selected characteristics along with identification data over a telephonic system to the central location; and displaying said selected characteristics at the central location, each of said previous steps occurring in a selected sequence for serial transmission to the central clinic.
 23. The method of claim 22 wherein detecting wave forms of said parameters includes: operatively attaching the patient to sending apparatus and activating same for sequentially reading parameters of Electrocardiogram.
 24. The method of claim 23 wherein the patient is an electronic cardiac pacer user and the diagnosis is for detecting the status of available energy of said cardiac pacer and said readings further include: sequentially reading additional parameters of the cardiac pacer including the cardiac pacer pulse wave form; and deriving from said cardiac pacer pulse wave form signals proportional to selected characteristics thereof and transmitting said signals proportional to the selected characteristics to the central location.
 25. The method of claim 24 wherein analyzing for transmission includes detecting the characteristics of the waveform including height, width, area under parameter pulses and frequence.
 26. The method of claim 24 wherein the step of deriving signals proportional to selected characteristics of the cardiac pacer pulse wave forms includes time expansion of the characteristics of the wave form including the steps of recording said characteristics in a storage device at a selected recording rate and reading out said stored information at selected different rates compatible with transmission apparatus to be utilized.
 27. The method of claim 26 wherein said different read out rate is substantially slower than the recording rate for transtelephonic transmission.
 28. The method of claim 22 wherein: analysis includes the step of time expanding the information at the remote location for rendering the information into signals compatible with the bandwidth of a transmission system, and including the step of recording the signals at the central location. 